SOLE CH 18 Gastrointestinal Alterations

26. The patient is being treated for an H. pylori infection with proton pump inhibitor, metronidazole, and tetracycline but is not responding. The nurse expects that a. bismuth will be added to the current triple therapy. b. a 6-day course of levofloxacin may be used. c. a second-line therapy is not usually effective. d. the proton pump inhibitor will be changed to a higher dose.

a. bismuth will be added to the current triple therapy. ANS: A Triple-agent therapy with a proton pump inhibitor and two antibiotics for 14 days is the recommended treatment for eradication of H. pylori. In case first-line therapy fails, a bismuth-based quadruple therapy has been proven to be effective in 76% of patients. This second-line therapy consists of a PPI, bismuth, metronidazole, and a tetracycline. A 10-day course of levofloxacin may also be administered as a second-line therapy for H. pylori infections.

28. The nurse is caring for a patient who is being treated for peptic ulcer disease. Suddenly, the patient yells that the pain has become extreme. The nurse notes that the patient's abdomen is rigid. The nurse should a. call the provider immediately. b. give the patient pain medication. c. remove the NG tube. d. give the patient an antacid.

a. call the provider immediately. ANS: A Perforation of the gastric mucosa is the major GI complication of peptic ulcer disease. The most common signs of this complication are an abrupt onset of abdominal pain, followed rapidly by signs of peritonitis. Emergent surgery is indicated for treatment. Pain medication is not the treatment of choice in this situation. These patients almost always have nasogastric tubes placed for gastric decompression. Antacids and histamine blockers may or may not be indicated, depending on the cause of the upper GI bleeding. Mortality rates for patients with perforations range from 10% to 40%, depending on the age and condition of the patient at the time of surgery; therefore, it is essential that the provider be called immediately. There is no indication that the NG tube should be removed based on the information provided. Removing it could complicate further assessment or treatment.

46. The patient is getting neomycin for treatment of hepatic encephalopathy. While the patient is receiving this medication, it is especially important that the nurse a. evaluate renal function studies daily. b. give the medication every 12 hours. c. evaluate liver studies for signs of neomycin-induced damage. d. obtain stool guaiac tests to ensure that pathogens are being destroyed.

a. evaluate renal function studies daily. ANS: A Neomycin is a broad-spectrum antibiotic that destroys normal bacteria found in the bowel, thereby decreasing protein breakdown and ammonia production. Neomycin is given orally every 4 to 6 hours. This drug is toxic to the kidneys (not liver) and therefore cannot be given to patients with renal failure. Daily renal function studies are monitored when neomycin is administered. Guaiac tests are used to detect occult bleeding.

39. Pain control is a nursing priority in patients with acute pancreatitis because pain a. increases pancreatic secretions. b. is caused by decreased distension of the pancreatic capsule. c. decreases the patient's metabolism. d. is caused by dilation of the biliary system.

a. increases pancreatic secretions. ANS: A Pain control is a nursing priority in patients with acute pancreatitis not only because the disorder produces extreme patient discomfort but also because pain increases the patient's metabolism and thus increases pancreatic secretions. The pain of pancreatitis is caused by edema and distension of the pancreatic capsule, obstruction of the biliary system, and peritoneal inflammation from pancreatic enzymes. Pain is often severe and unrelenting and is related to the degree of pancreatic inflammation.

37. The nurse is caring for a patient with severe pancreatitis who is orally intubated and on mechanical ventilation. The patient's calcium level this morning was 5.5 mg/dL. The nurse notifies the provider and a. places the patient on seizure precautions. b. expects that the provider will come and remove the endotracheal tube. c. withholds any further calcium treatments. d. places an oral airway at the bedside.

a. places the patient on seizure precautions. ANS: A Patients with severe hypocalcemia (serum calcium level less than 6 mg/dL) should be placed on seizure precaution status, and respiratory support equipment should be available (e.g., oral airway, suction). In this case, the patient is already intubated so an oral airway is not needed. This value is critically low, and replacement of calcium is expected.

1. Vascular sounds such as bruits, heard in the abdomen during physical assessment, may indicate which of the following? (Select all that apply.) a. Obstructed portal circulation b. Dilated vessels c. Tortuous vessels d. Constricted vessels e. Presence of an abscess

b. Dilated vessels c. Tortuous vessels d. Constricted vessels ANS: B, C, D Vascular sounds such as bruits may be heard and may indicate dilated, tortuous, or constricted vessels. Venous hums are also normally heard from the inferior vena cava. A hum in the periumbilical region in a patient with cirrhosis indicates obstructed portal circulation. Peritoneal friction rubs may also be heard and may indicate infection, abscess, or tumor.

5. The patient is admitted with end-stage liver disease. The nurse evaluates the patient for which of the following? (Select all that apply.) a. Hypoglycemia b. Malnutrition c. Ascites d. Hypercoagulation e. Disseminated intravascular coagulation

b. Malnutrition c. Ascites e. Disseminated intravascular coagulation ANS: B, C, E Altered carbohydrate metabolism may result in unstable blood glucose levels. The serum glucose level is usually increased to more than 200 mg/dL. This condition is termed cirrhotic diabetes. Altered carbohydrate metabolism may also result in malnutrition and a decreased stress response. Protein metabolism, albumin synthesis, and serum albumin levels are decreased. Low albumin levels are also thought to be associated with the development of ascites, a complication of hepatic failure. Fibrinogen is an essential protein that is necessary for normal clotting. A low plasma fibrinogen level, coupled with decreased synthesis of many blood-clotting factors, predisposes the patient to bleeding. Clinical signs and symptoms range from bruising and nasal and gingival bleeding to frank hemorrhage. Disseminated intravascular coagulation may also develop.

29. The patient is admitted for GI bleeding, but the source is unknown. Before ordering endoscopy, the provider orders octreotide to be given intravenously. The purpose of this medication is to a. increase portal pressure and improve liver function. b. decrease splanchnic blood flow and portal pressure. c. vasodilate the splanchnic arteriolar bed. d. increase blood flow in the liver's collateral circulation.

b. decrease splanchnic blood flow and portal pressure. ANS: B Octreotide is commonly ordered to slow or stop bleeding. Early administration provides for stabilization before endoscopy. These drugs decrease splanchnic blood flow, reduce portal pressure, and have minimal adverse effects Octreotide does not increase portal pressure, vasodilate the splanchnic arteriolar bed, or increase blood flow in the liver's collateral circulation.

35. The patient is admitted with acute pancreatitis and is demonstrating severe abdominal pain, vomiting, and ascites. Using the Ranson classification criteria, the nurse determines that this patient a. has a 99% chance of survival. b. has a 15% chance of dying. c. has a 40% chance of dying. d. has no chance of survival.

b. has a 15% chance of dying. ANS: B Patients with acute pancreatitis can develop mild or fulminant disease. As a consequence, research has addressed criteria for predicting the prognosis of patients with acute pancreatitis. The early classification criteria were developed by Ranson, who suggested that the number of signs present within the first 48 hours of admission directly relates to the patient's chance of significant morbidity and mortality. In Ranson's research, patients with fewer than three signs had a 1% mortality rate, those with three or four signs had a 15% mortality rate, those with five or six signs had a 40% mortality rate, and those with seven or more signs had a 100% mortality rate.

44. The nurse is caring for a patient with severe ascites due to chronic liver failure. The patient is lying supine in bed and complaining of difficulty breathing. The nurse's first action should be to a. measure abdominal girth to determine the amount of fluid accumulation. b. position the patient in a semi-Fowler's position. c. prepare the patient for emergent paracentesis. d. administer diuretics.

b. position the patient in a semi-Fowler's position. ANS: B Ascites is problematic because as more fluid is retained, it pushes up on the diaphragm, thereby impairing breathing. Positioning the patient in a semi-Fowler's position allows for free diaphragm movement. Frequent monitoring of abdominal girth alerts the nurse to fluid accumulation, but the most immediate and easiest action would be to place the patient in semi-Fowler's position. Paracentesis is sometimes done to relieve symptoms, but it is not usually done emergently. Diuretics must be administered cautiously because if the intravascular volume is depleted too quickly, acute renal failure may be induced.

42. The patient is diagnosed with hepatitis. In caring for this patient, the nurse should a. administer anti-inflammatory medications. b. provide rest, nutrition, and antiemetics if needed. c. provide antianxiety medications freely to decrease agitation. d. instruct the patient to take over-the-counter anti-inflammatory medications at home.

b. provide rest, nutrition, and antiemetics if needed. ANS: B No definitive treatment for acute inflammation of the liver exists. Goals for medical and nursing care include providing rest and assisting the patient in obtaining optimal nutrition. Medications to help the patient rest or to decrease agitation must be closely monitored because most of these drugs require clearance by the liver, which is impaired during the acute phase. Nursing measures such as administration of antiemetics may be helpful. Small, frequent, palatable meals and supplements should be offered. Patients must be instructed not to take any over-the-counter drugs that can cause liver damage. Alcohol should be avoided.

33. The patient is admitted with severe abdominal pain due to pancreatitis. The patient asks the nurse, "What causes this? Why does it hurt so much?" The nurse should answer: a. "Pancreatitis is extremely rare, and no one knows why it causes pain." b. "Pancreatitis is caused by diabetes; you should be checked." c. "Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain." d. "The pain is localized to the pancreas. Fortunately, it will not affect anything else."

c. "Injury to certain cells in the pancreas causes it to digest (eat) itself, causing pain." ANS: C The most common theory regarding the development of pancreatitis is that an injury or disruption of pancreatic acinar cells allows leakage of the pancreatic enzymes into pancreatic tissue. The leaked enzymes (trypsin, chymotrypsin, and elastase) become activated in the tissue and start the process of autodigestion. Pancreatitis is one of the most common pancreatic diseases; it is not caused by diabetes. The activated enzymes break down tissue and cell membranes, causing edema, vascular damage, hemorrhage, necrosis, and fibrosis. These now toxic enzymes and inflammatory mediators are released into the bloodstream and cause injury to vessel and organ systems, such as the hepatic and renal systems.

47. Metronidazole is being given to treat hepatic encephalopathy. When administering this medication, the nurse a. watches the patient for diarrhea. b. evaluates renal function daily. c. assesses the patient for epigastric discomfort. d. instructs the patient that this medication must be taken for 2 weeks.

c. assesses the patient for epigastric discomfort. ANS: C Neomycin and metronidazole are considered second-line treatments for hepatic encephalopathy. Metronidazole is given 500 mg to 1.5 g/day for 1 week. Metronidazole does not cause diarrhea, and it is not nephrotoxic. Metronidazole may cause epigastric discomfort, which may in turn result in poor compliance with long-term treatment.

31. The nurse is caring for a patient with a Minnesota tube in place when the patient suddenly shows signs of severe pain and respiratory distress. The nurse should a. cut the gastric balloon lumen and watch for improved symptoms. b. cut the esophageal lumen and watch for improvement. c. cut all three lumens and remove the tube. d. call the provider with an update of the patient's condition.

c. cut all three lumens and remove the tube. ANS: C Spontaneous rupture of the gastric balloon, upward migration of the tube, and occlusion of the airway are other possible life-threatening complications that need to be assessed. Esophageal rupture may also occur and is characterized by the abrupt onset of severe pain. In the event of any of these life-threatening emergencies, all three lumens are cut and the entire tube is removed. For this reason, scissors are kept at the patient's bedside at all times. Endotracheal intubation is strongly recommended to protect the airway.

24. The patient has a hemoglobin of 8.5 g/dL and hematocrit of 27%. The nurse administers 2 units of packed red blood cells to the patient and repeats the lab work a few hours later. The new hemoglobin and hematocrit would be expected to be a. hemoglobin 7.5 g/dL and hematocrit 25%. b. hemoglobin 9.5 g/dL and hematocrit 29%. c. hemoglobin 10.5 g/dL and hematocrit 32%. d. hemoglobin 12.5 g/dL and hematocrit 36%.

c. hemoglobin 10.5 g/dL and hematocrit 32%. ANS: C One unit of packed RBCs can be expected to increase the Hgb value by 1 g/dL and the Hct value by 2% to 3%, but this effect is influenced by the patient's intravascular volume status and whether the patient is actively bleeding.

14. When assessing the patient's bowel sounds, the nurse a. listens to the abdomen after palpation is done. b. places the patient in a relaxed prone position. c. listens to bowel sounds before palpation. d. places a pillow over the patient's knees.

c. listens to bowel sounds before palpation. ANS: C Bowel sounds are high-pitched, gurgling sounds caused by air and fluid as they move through the GI tract. Bowel sounds are auscultated before palpation. However, auscultation after palpation can be done if no bowel sounds were heard to stimulate peristalsis. Optimal positioning of the patient to relax the abdomen is performed before auscultation is begun. A supine position with the patient's arms at the sides or folded at the chest is usually recommended. Placing a pillow under the patient's knees also helps to relax the abdominal wall.

41. The patient is admitted with acute pancreatitis and is later diagnosed as having a pseudocyst. The nurse realizes that a. surgery for pseudocysts must be done immediately. b. a cholecystectomy is usually done when pseudocysts are found. c. pseudocysts may resolve spontaneously, so surgery may be delayed. d. pseudocysts require pancreatic resection, removing the entire pancreas.

c. pseudocysts may resolve spontaneously, so surgery may be delayed. ANS: C Surgery may be indicated for pseudocysts; however, it is usually delayed because some pseudocysts resolve spontaneously. Surgery may also be performed when gallstones are thought to be the cause of the acute pancreatitis. A cholecystectomy is usually performed. Pancreatic resection for acute necrotizing pancreatitis may be performed to prevent systemic complications of the disease process. In this procedure, dead or infected pancreatic tissue is surgically removed while most of the gland is preserved. The indication for surgical intervention is clinical deterioration of the patient despite the use of conventional treatments, or the presence of peritonitis.

23. The patient is being admitted with GI bleeding. Blood work includes serial hemoglobin and hematocrit levels. The nurse understands that a. the hematocrit is a direct reflection of quick blood loss. b. as extravascular fluid enters the vascular space, the hematocrit increases. c. the hematocrit value does not change substantially during the first few hours. d. the administration of intravenous fluids has no effect on hematocrit levels.

c. the hematocrit value does not change substantially during the first few hours. ANS: C The hematocrit (Hct) value does not change substantially during the first few hours after an acute bleeding episode. During this time, the severity of the bleeding must not be underestimated. Only when extravascular fluid enters the vascular space to restore volume does the Hct value decrease. This effect is further complicated by fluids and blood products that are administered during the resuscitation period.

40. The nurse is caring for a patient with acute pancreatitis. To provide adequate pain control, the nurse a. should suggest that the patient receive epidural analgesia. b. provides oral pain medication on an "as needed" (PRN) basis. c. removes any nasogastric tubes. d. administers pain medication on a routine schedule.

d. administers pain medication on a routine schedule. ANS: D Analgesic administration is a nursing priority. Adequate pain control requires the use of IV opiates, often in the form of a patient-controlled analgesia (PCA) pump. In the case in which a PCA pump is not ordered, pain medications are administered on a routine schedule, rather than as needed, to prevent uncontrollable abdominal pain. Insertion of a nasogastric tube connected to low intermittent suction may help ease pain.

32. The nurse is caring for a patient who has had a portacaval shunt placed surgically. The nurse is aware that this procedure a. improves survival in patients with varices. b. decreases the risk of encephalopathy. c. decreases the incidence of ascites. d. decreases rebleeding.

d. decreases rebleeding. ANS: D Surgical shunts decrease rebleeding but do not improve survival. The procedure is associated with a higher risk of encephalopathy and makes liver transplantation, if needed, more difficult. A temporary increase in ascites occurs after all these procedures, and careful assessments and interventions are required in the care of this patient population.

38. Trends in nutritional management of the patient with pancreatitis are changing. As a result, the nurse understands that a. patients with pancreatitis must eat nothing in order to prevent release of secretin. b. nasogastric suction is essential in treating patients with pancreatitis. c. a nasogastric tube is no longer required to treat patients with ileus. d. immediate oral feeding in patients with mild pancreatitis may help recovery.

d. immediate oral feeding in patients with mild pancreatitis may help recovery. ANS: D Nasogastric suction and "nothing by mouth" status were classic treatments for patients with acute pancreatitis to suppress pancreatic exocrine secretion by preventing the release of secretin from the duodenum. Normally, secretin, which stimulates pancreatic secretion production, is stimulated when acid is in the duodenum; therefore, nasogastric suction has been a primary treatment. Nausea, vomiting, and abdominal pain may also be decreased with nasogastric suctioning. A nasogastric tube is also necessary in patients with ileus, severe gastric distension, and a decreased level of consciousness to prevent complications resulting from pulmonary aspiration. However, trends in nutritional management are changing. NPO status and NG suction are not used as much, especially for mild cased. Early nutritional support may be ordered to prevent atrophy of gut lymphoid tissue, prevent bacterial overgrowth in the intestine, and increase intestinal permeability. Immediate oral feeding in patients with mild acute pancreatitis is safe and may accelerate recovery. Early enteral nutrition appears effective and safe.

25. The patient is ordered to have large-volume gastric lavage. The nurse will most likely need to a. insert a small-bore nasogastric tube. b. use 2 to 4 liters of room-temperature normal saline. c. remove the nasogastric tube before lavage is started. d. insert a large-bore nasogastric tube.

d. insert a large-bore nasogastric tube. ANS: D Large-volume gastric lavage before endoscopy for acute upper gastrointestinal bleeding is safe and provides better visualization of the gastric fundus. A large-bore nasogastric tube is inserted and is connected to suction. If lavage is ordered, 1 to 2 liters of room-temperature normal saline is instilled via nasogastric tube and is then gently removed by intermittent suction or gravity until the secretions are clear. After lavage, the nasogastric tube may be left in or removed.

15. When assessing bowel sounds, the nurse a. uses the "bell" part of the stethoscope. b. listens at least 15 minutes. c. expects bowel sounds to be regular in rhythm. d. listens for 5 minutes before noting "absent bowel sounds."

d. listens for 5 minutes before noting "absent bowel sounds." ANS: D Bowel sounds are best heard with the diaphragm of the stethoscope and are systematically assessed in all four quadrants of the abdomen. The frequency and character of the sounds are noted. The frequency of bowel sounds has been estimated at 5 to 35 per minute, and the sounds are usually irregular. The amount of time for bowel sounds to be auscultated ranges from 30 seconds to up to 7 minutes. It is recommended that bowel sounds be assessed a minimum of 5 minutes before an assessment of absence of bowel sounds can be made.

The patient is admitted with acute pancreatitis. The nurse should a. assess pain level because pancreatic pain is unique in character. b. examine laboratory values for low amylase levels. c. expect lipase levels to decrease within 24 hours. d. evaluate C-reactive protein as a gauge of severity.

ANS: D.) evaluate C-reactive protein as a gauge of severity. d. C-reactive protein is a useful marker for assessing the severity of inflammation and complications in acute pancreatitis, making it the most appropriate choice. here's why the others are incorrect: a. While assessing pain is important, pancreatic pain can vary and isn't uniquely identifiable. b. Amylase levels are typically elevated in acute pancreatitis, not low. c. Lipase levels usually remain elevated for a longer period, not decreasing within 24 hours.

4. The nurse is caring for a patient who is receiving several cardiac medications designed to stimulate the sympathetic nervous system, vitamin B12, and an H2 blocker. The nurse should do which of the following? a. Assess for signs of peptic ulcer. b. Be watchful for increased saliva production. c. Evaluate for a decrease in potassium level. d. Give the patient medications to prevent anemia.

ANS: a.) Assess for signs of peptic ulcer. a. Assess for signs of peptic ulcer:This is correct. H2 blockers are used to reduce stomach acid and prevent ulcers, but stimulating the sympathetic nervous system can potentially lead to increased stomach acid secretion and ulcer formation. Therefore, monitoring for signs of peptic ulcer is important. b. Be watchful for increased saliva production:This is incorrect. Sympathetic stimulation typically decreases saliva production, leading to drier mouth rather than increased saliva. c. Evaluate for a decrease in potassium level:While some medications can affect potassium levels, there's no direct connection in this scenario that necessitates specific monitoring for decreased potassium related to the medications mentioned. d. Give the patient medications to prevent anemia:This is not necessarily correct. Vitamin B12 is important for preventing anemia, but if the patient is already receiving B12, additional medications to prevent anemia may not be needed unless there is a specific indication.

18. The patient is admitted with upper GI bleeding following an episode of forceful retching following excessive alcohol intake. The nurse suspects a Mallory-Weiss tear and is aware that a. a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa. b. this type of bleeding is treated by giving chewable aspirin. c. the bleeding, although impressive, is self-limiting with little actual blood loss. d. it is not usually associated with alcohol intake or retching.

ANS: a.) a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa. a. a Mallory-Weiss tear is a longitudinal tear in the gastroesophageal mucosa:This statement is accurate. A Mallory-Weiss tear occurs at the junction of the stomach and esophagus and is often caused by forceful vomiting or retching, which aligns with the patient's history of excessive alcohol intake and forceful retching. b. this type of bleeding is treated by giving chewable aspirin:This is incorrect. Aspirin can actually increase the risk of bleeding, especially in cases of gastrointestinal bleeding. Treatment typically involves supportive care, and in some cases, intervention may be required. c. the bleeding, although impressive, is self-limiting with little actual blood loss:While Mallory-Weiss tears can be self-limiting, they can also lead to significant blood loss, depending on the severity of the tear and the individual's condition. This statement downplays the potential seriousness of the bleeding. d. it is not usually associated with alcohol intake or retching:This is incorrect. Mallory-Weiss tears are indeed often associated with episodes of excessive alcohol intake and forceful vomiting or retching.

9. The liver detoxifies the blood by a. converting fat-soluble compounds to water-soluble compounds. b. converting water-soluble compounds to fat-soluble compounds. c. excreting fat-soluble compounds in feces. d. metabolizing inactive toxic substances to active forms.

ANS: a.) converting fat-soluble compounds to water-soluble compounds. a. converting fat-soluble compounds to water-soluble compounds:This is correct. The liver detoxifies the blood by converting fat-soluble toxins (like certain drugs and alcohol) into water-soluble compounds, making it easier for the kidneys to excrete them in urine. b. converting water-soluble compounds to fat-soluble compounds:This is incorrect. The liver does not convert water-soluble compounds to fat-soluble ones for detoxification; this would make elimination harder. c. excreting fat-soluble compounds in feces:This is misleading. While the liver does excrete some substances into bile (which can be eliminated in feces), detoxification primarily involves converting compounds to water-soluble forms for urinary excretion. d. metabolizing inactive toxic substances to active forms:This is incorrect. The liver typically aims to metabolize active toxins into inactive forms for elimination, not the other way around.

16. Infection by Helicobacter pylori bacteria is a major cause of a. duodenal ulcers. b. Cushing's ulcers. c. Curling's ulcers. d. stress ulcers.

ANS: a.) duodenal ulcers a. duodenal ulcers:Helicobacter pylori (H. pylori) infection is a well-established cause of duodenal ulcers. This bacterium damages the stomach lining and is associated with increased acid production, leading to ulcer formation in the duodenum. b. Cushing's ulcers:Cushing's ulcers are a type of stress-related mucosal disease associated with increased intracranial pressure and are not primarily caused by H. pylori. c. Curling's ulcers:Curling's ulcers occur in patients who have severe burns or other acute stressors, and they are not directly related to H. pylori infection. d. stress ulcers:While stress ulcers can occur in critically ill patients, they are not specifically caused by H. pylori. Stress ulcers are typically associated with physiological stress, not bacterial infection.

36. The patient is admitted with pancreatitis and has severe ascites. In caring for this patient, the nurse should a. monitor the patient's blood pressure and evaluate for signs of dehydration. b. restrict intravenous and oral fluid intake because of fluid shifts. c. avoid the use of colloid IV solutions in managing the patient's fluid status. d. only use crystalloid fluids to prevent IV lines from clotting.

ANS: a.) monitor the patient's blood pressure and evaluate for signs of dehydration. a.) "Monitor the patient's blood pressure and evaluate for signs of dehydration.": This is correct. In pancreatitis with severe ascites, it's important to monitor blood pressure as fluid shifts can affect hemodynamics, and signs of dehydration may arise from fluid loss. b.) "Restrict intravenous and oral fluid intake because of fluid shifts.": This is misleading. While careful management of fluid intake is important, complete restriction is not typically indicated; monitoring and appropriate fluid management are crucial. c.) "Avoid the use of colloid IV solutions in managing the patient's fluid status.": This is incorrect. Colloids can be beneficial in certain cases of fluid resuscitation, especially when managing ascites and maintaining blood volume. d.) "Only use crystalloid fluids to prevent IV lines from clotting.": This is too restrictive and not entirely accurate. While crystalloid fluids are commonly used, it's not the only option, and other fluids may be necessary for adequate resuscitation and management of ascites.

20. The patient is admitted with generalized fatigue and low hemoglobin and hematocrit levels. The patient denies vomiting and states that the last bowel movement earlier that day was normal in color and consistency. However, because GI blood loss can be a cause of anemia, the nurse should expect to a. obtain a stool sample for guaiac testing. b. chart that the patient reports the presence of melena in his stool. c. inspect the patient's next stool for the presence of coffee-ground contents. d. obtain guaiac positive stools only if bleeding is current.

ANS: a.) obtain a stool sample for guaiac testing. a. Obtain a stool sample for guaiac testing: This is the best action because guaiac testing is used to detect hidden (occult) blood in the stool, which can indicate gastrointestinal bleeding even if the patient reports normal stool color and consistency. b.Chart that the patient reports the presence of melena in his stool: This is incorrect because the patient specifically denies any vomiting or changes in stool color, which would suggest melena (black, tarry stools). c. Inspect the patient's next stool for the presence of coffee-ground contents: This option is not appropriate since coffee-ground appearance in stool typically indicates upper GI bleeding, and the patient has not reported any related symptoms. d. Obtain guaiac positive stools only if bleeding is current: This is misleading. Guaiac testing can detect past bleeding, not just current. It's important to test even if the patient denies any symptoms.

19. The nurse is caring for a patient who is passing bright red blood rectally. The nurse should expect to insert a nasogastric tube to a. rule out massive upper GI bleeding. b. detect the presence of melena in the stomach. c. visually determine the presence of occult bleeding. d. obtain samples for guaiac to confirm current bleeding.

ANS: a.) rule out massive upper GI bleeding. a. rule out massive upper GI bleeding:This statement is correct. In a patient presenting with bright red blood rectally, inserting a nasogastric (NG) tube can help assess whether the source of bleeding is from the upper gastrointestinal (GI) tract. If the NG tube returns bright red blood, it indicates that there may be significant upper GI bleeding. b. detect the presence of melena in the stomach:This is incorrect. Melena refers to black, tarry stools, which result from the digestion of blood in the upper GI tract. An NG tube can help assess the stomach contents, but it wouldn't specifically be used to detect melena since melena is related to stool rather than stomach contents. c. visually determine the presence of occult bleeding:This is incorrect. Occult bleeding refers to blood that is not visible and typically requires specific tests (like a guaiac test) to detect. An NG tube would not help in visually determining occult bleeding. d. obtain samples for guaiac to confirm current bleeding:This is incorrect. While a guaiac test is used to detect hidden blood in stool, it does not involve an NG tube. Guaiac testing is typically performed on stool samples, not gastric contents.

5. After gastric bypass surgery, the patient is getting vitamin B12 injections. The patient asks about the purpose of this vitamin. The nurse explains that a. vitamin B12 is needed for the formation of red blood cells. b. vitamin B12 is needed to prevent a type of anemia. c. vitamin B12 is essential for surgical wound healing. d. vitamin B12 is always deficient in obese people.

ANS: a.) vitamin B12 is needed for the formation of red blood cells. a. Vitamin B12 is needed for the formation of red blood cells:This statement is true. Vitamin B12 is crucial for producing red blood cells, and a deficiency can lead to anemia. b. Vitamin B12 is needed to prevent a type of anemia:While this is also true (specifically, vitamin B12 deficiency can lead to megaloblastic anemia), it doesn't fully capture the broader role of vitamin B12 in red blood cell formation, making option a a more comprehensive answer. c. Vitamin B12 is essential for surgical wound healing:This is misleading. While adequate nutrition is important for healing, vitamin B12 is not specifically known for directly aiding surgical wound healing. d. Vitamin B12 is always deficient in obese people:This statement is incorrect. Vitamin B12 deficiency is not a universal condition in obese individuals; deficiencies can occur in anyone, particularly after surgeries like gastric bypass that affect nutrient absorption.

22. The patient is admitted with the diagnosis of GI bleeding. The patient's heart rate is 140 beats per minute, and the blood pressure is 84/44 mm Hg. These values may indicate: a. a need for hourly vital signs. b. approximately 25% loss of total blood volume. c. resolution of hypovolemic shock. d. increased blood flow to the skin, lungs, and liver.

ANS: b.) approximately 25% loss of total blood volume. a. A need for hourly vital signs: While frequent monitoring is important in this situation, the provided values indicate a more serious condition than just a need for increased monitoring. b. Approximately 25% loss of total blood volume: This is correct. A heart rate of 140 beats per minute and a blood pressure of 84/44 mm Hg suggest significant hypovolemia, typically associated with a loss of about 20-25% of total blood volume. c. Resolution of hypovolemic shock: This is incorrect. The patient's vital signs indicate ongoing shock rather than resolution, as evidenced by a high heart rate and low blood pressure. d. Increased blood flow to the skin, lungs, and liver: This is not accurate. In hypovolemic shock, blood flow is typically prioritized to vital organs (like the heart and brain) rather than the skin, which may be pale or cool due to vasoconstriction

7. The nurse is caring for a patient with liver disease. When assessing the patient's laboratory values, the nurse should a. disregard the level of conjugated bilirubin. b. assess the total bilirubin c. call the provider immediately if the direct bilirubin is elevated. d. be aware that unconjugated bilirubin is harmless.

ANS: b.) assess the total bilirubin a. Disregard the level of conjugated bilirubin:This is incorrect. Conjugated bilirubin levels are important in assessing liver function and the body's ability to process bilirubin. b. Assess the total bilirubin:This is correct. Total bilirubin includes both conjugated (direct) and unconjugated (indirect) bilirubin, and assessing it provides valuable information about liver function and possible hemolysis. c. Call the provider immediately if the direct bilirubin is elevated:This is not necessarily correct without context. While elevated direct bilirubin can indicate liver dysfunction or bile duct obstruction, the urgency depends on the overall clinical picture and other lab results. d. Be aware that unconjugated bilirubin is harmless:This is misleading. While unconjugated bilirubin itself may not be harmful, elevated levels can indicate underlying issues such as hemolysis or liver dysfunction that need to be addressed.

27. The nurse is to assist the provider in performing bedside endoscopy on a patient. To prevent respiratory complications, the nurse places the patient a. supine in Trendelenburg position. b. in a left lateral reverse Trendelenburg position. c. flat with the feet elevated. d. in a semi-Fowler's position.

ANS: b.) in a left lateral reverse Trendelenburg position. a. Supine in Trendelenburg position: This position may not be optimal for respiratory function, as it can increase pressure on the diaphragm and hinder breathing. b. In a left lateral reverse Trendelenburg position: This is the correct choice. This position helps prevent aspiration during endoscopy by keeping the airway clear and allowing for easier access for the procedure. c. Flat with the feet elevated: While elevating the feet can help with circulation, it does not specifically help with respiratory protection during endoscopy. d. In a semi-Fowler's position: This position is generally beneficial for respiratory comfort but is not the best choice for preventing aspiration during a procedure like endoscopy.

11. The nurse is caring for a patient with a heart rate of 140 beats/min. The provider orders parasympathetic medications to slow down the heart rate. With this type of medication, the nurse should a. evaluate the patient for symptoms of constipation. b. observe for diarrhea. c. assess mucous membranes for signs of dryness. d. expect decreased bowel sounds.

ANS: b.) observe for diarrhea. a. evaluate the patient for symptoms of constipation:This is incorrect because parasympathetic medications usually increase bowel motility rather than decrease it. If anything, these medications can lead to increased activity in the gastrointestinal tract, making constipation less likely. b. observe for diarrhea:This is correct. Parasympathetic stimulation increases secretions and motility in the gut, which can lead to diarrhea. Therefore, observing for diarrhea is an appropriate action when administering parasympathetic medications. c. assess mucous membranes for signs of dryness:This is incorrect because parasympathetic stimulation typically promotes secretions, including saliva and mucus. Therefore, mucous membranes are less likely to be dry in this context. d. expect decreased bowel sounds:This is incorrect because parasympathetic medications usually enhance gastrointestinal motility, which often correlates with increased bowel sounds. Decreased bowel sounds would not be expected with parasympathetic stimulation.

1. The patient is admitted with constipation. In anticipation of treatment, the nurse prepares to: a. give medications that will suppress the autonomic nervous system. b. provide therapies that will innervate the autonomic nervous system. c. teach the patient that the submucosa is the innermost part of the gut wall. d. give medications intravenously because the submucosa has no blood vessels.

ANS: b.) provide therapies that will innervate the autonomic nervous system. b. provide therapies that will innervate the autonomic nervous system. This is correct as stimulating the ANS can help promote bowel motility and relieve constipation. here's why the others are incorrect: a. give medications that will suppress the autonomic nervous system. This is not appropriate because suppressing the ANS would likely worsen constipation. c. teach the patient that the submucosa is the innermost part of the gut wall. This is incorrect; the innermost layer is the mucosa, not the submucosa. d. give medications intravenously because the submucosa has no blood vessels. This is misleading; the submucosa does contain blood vessels, and medications can be given orally for constipation.

2. The nurse is assessing the patient and notices that the oral cavity is only slightly moist and contains a scant amount of thick saliva even though the patient's fluid intake has been sufficient. The nurses realizes that the condition of the patient's mouth is probably caused by a. thoughts of food. b. sympathetic nerve stimulation. c. overstimulation of the sublingual glands. d. parasympathetic nerve stimulation.

ANS: b.) sympathetic nerve stimulation. a. thoughts of food. While thoughts of food can stimulate salivation, they typically lead to increased saliva production, not decreased. b. sympathetic nerve stimulation. This is correct because sympathetic stimulation generally inhibits saliva production, leading to a dry or less moist oral cavity. c. overstimulation of the sublingual glands. This is unlikely because overstimulation would increase saliva production, not decrease it. d. parasympathetic nerve stimulation. This typically increases saliva production and moisture in the mouth, so it's not the cause of the observed condition.

45. Lactulose is considered the first-line treatment for hepatic encephalopathy and works by a. causing ammonia to enter the bloodstream via the colon. b. trapping ammonia in the bowel for excretion. c. causing constipation and inhibiting the excretion of ammonia. d. creating an alkaline environment in the bowel.

ANS: b.) trapping ammonia in the bowel for excretion. b. trapping ammonia in the bowel for excretionLactulose works by acidifying the contents of the bowel, which converts ammonia (NH₃) into ammonium (NH₄⁺), trapping it in the bowel and promoting its excretion through feces. This helps to reduce ammonia levels in the bloodstream. Why the others are incorrect: a. causing ammonia to enter the bloodstream via the colonThis is incorrect; lactulose prevents ammonia from entering the bloodstream by facilitating its excretion. c. causing constipation and inhibiting the excretion of ammoniaLactulose actually works as an osmotic laxative, promoting bowel movements to enhance ammonia elimination, not causing constipation. d. creating an alkaline environment in the bowelLactulose actually creates an acidic environment, which is crucial for trapping ammonia in the bowel.

21. The nurse is caring for a patient with active GI bleeding. Estimated blood loss is 1,000 mL. Which of the following assessments would the nurse expect to find with this amount of blood loss? a. All vital signs would expect to be normal. b. Oral temperature of 103°. c. Heart rate 125 beats per minute. d. Systolic blood pressure of 120 mm Hg.

ANS: c.) Heart rate 125 beats per minute. a. All vital signs would expect to be normal: This is incorrect because significant blood loss typically leads to changes in vital signs, such as increased heart rate and possibly decreased blood pressure. b.Oral temperature of 103°: This is not directly related to blood loss. While fever can occur for various reasons, it is not a typical response to blood loss. c. Heart rate 125 beats per minute: This is expected. With significant blood loss, the body compensates by increasing the heart rate (tachycardia) to maintain adequate blood flow and oxygen delivery to tissues. d.Systolic blood pressure of 120 mm Hg: This is not expected after a 1,000 mL blood loss, as significant blood loss typically results in hypotension (lower blood pressure), especially if the loss is acute and the body is unable to compensate effectively.

6. The nurse is assessing a patient admitted with pancreatitis. In doing so, the nurse a. palpates the pancreas for size and shape. b. emphasizes to the patient that pancreatic inflammation does not spread. c. assesses symptoms that could indicate involvement of the stomach. d. explains to the patient that back pain is not a sign of pancreatitis.

ANS: c.) assesses symptoms that could indicate involvement of the stomach. a. Palpates the pancreas for size and shape:This is incorrect because the pancreas is located deep in the abdomen and is not easily palpable during a physical examination. b. Emphasizes to the patient that pancreatic inflammation does not spread:This is misleading. Pancreatitis can lead to complications that may involve surrounding structures, so inflammation can indeed affect nearby organs. c. Assesses symptoms that could indicate involvement of the stomach:This is correct. Symptoms of pancreatitis can sometimes mimic or involve issues with the stomach, such as nausea, vomiting, and abdominal pain, so it's important to assess for these. d. Explains to the patient that back pain is not a sign of pancreatitis:This is incorrect. Back pain can actually be a common symptom of pancreatitis, as the pain may radiate to the back.

13. The nurse is assessing a patient who is admitted with abdominal pain. To detect abdominal masses, the nurse a. observes for skin pigmentation and discolorations. b. looks for pulsations originating from the vena cava. c. has the patient take a deep breath. d. watches for signs of pain and distension.

ANS: c.) has the patient take a deep breath. a. observes for skin pigmentation and discolorations:This method does not directly help in detecting abdominal masses. While skin changes might indicate certain conditions, they don't specifically reveal the presence of masses. b. looks for pulsations originating from the vena cava:Observing for pulsations can be useful in assessing vascular issues, but it does not effectively help in identifying solid masses in the abdomen. c. has the patient take a deep breath:This is the correct choice. When the patient takes a deep breath, the diaphragm moves downward, allowing for better palpation of the abdominal organs. This technique can help the nurse feel for any abnormalities, including masses. d. watches for signs of pain and distension:While monitoring for pain and distension is important, these signs alone do not specifically indicate the presence of masses. They can suggest various abdominal issues but do not provide the tactile information needed for detection.

8. The liver plays a major role in homeostasis by a. synthesizing factor I but not factor II. b. synthesizing clotting factors without the need for vitamin K. c. removing active clotting factors from the circulation. d. synthesizing factor II but not factor I.

ANS: c.) removing active clotting factors from the circulation. a. synthesizing factor I but not factor II:This is incorrect. The liver synthesizes both fibrinogen (factor I) and prothrombin (factor II), along with several other clotting factors. b. synthesizing clotting factors without the need for vitamin K:This is incorrect. The synthesis of certain clotting factors (II, VII, IX, and X) depends on vitamin K. Without it, these factors cannot be produced effectively. c. removing active clotting factors from the circulation:This is correct. The liver plays a crucial role in maintaining homeostasis by removing active clotting factors from the bloodstream, helping to regulate coagulation. d. synthesizing factor II but not factor I:This is incorrect. As mentioned, the liver synthesizes both factor I (fibrinogen) and factor II (prothrombin).

12. In assessing the patient complaining of abdominal pain, it is important for the nurse to understand that a. pain receptors in the abdomen are more likely to be localized. b. pain of a peptic ulcer is easily distinguished from that of heart attack. c. visceral pain often leads to tachycardia and hypertension. d. increasing intensity of pain is always significant.

ANS: d.) increasing intensity of pain is always significant. a. pain receptors in the abdomen are more likely to be localized:This is incorrect because abdominal pain, especially visceral pain, is often poorly localized. It's typically diffuse and harder to pinpoint. b. pain of a peptic ulcer is easily distinguished from that of heart attack:This is incorrect because the symptoms of a peptic ulcer can closely resemble those of a heart attack, making them difficult to differentiate without further evaluation. c. visceral pain often leads to tachycardia and hypertension:While visceral pain can trigger a sympathetic response, this statement doesn't necessarily highlight the significance of increasing pain intensity. d. increasing intensity of pain is always significant:This is correct because an increase in pain intensity can indicate worsening conditions or complications, making it a key indicator for nurses to monitor. It often warrants further assessment and intervention.

17. The nurse is caring for a patient with the diagnosis of sepsis. The patient is on a ventilator in the critical care unit, and is receiving a proton pump inhibitor (PPI) to reduce the risk for a stress ulcer. In this scenario, a stress ulcer is likely to be secondary to a. infection with Helicobacter pylori bacteria. b. decreased acetylcholine production. c. a decreased number of parietal cells. d. ischemia associated with sepsis.

ANS: d.) ischemia associated with sepsis. a. infection with Helicobacter pylori bacteria:While H. pylori is a common cause of peptic ulcers, stress ulcers are generally not directly caused by this infection. Stress ulcers are more related to physiological stress rather than bacterial infection. b. decreased acetylcholine production:Decreased acetylcholine may affect gastric secretions, but it is not the primary factor in the development of stress ulcers. Stress ulcers are more related to the body's response to stress rather than neurotransmitter levels. c. a decreased number of parietal cells:A decrease in parietal cells would typically lead to lower acid production, which is not directly linked to the formation of stress ulcers. Stress ulcers are primarily related to stress responses and ischemia rather than a lack of parietal cells. d. ischemia associated with sepsis:This is the correct answer. In sepsis, reduced blood flow can lead to ischemia in the gastrointestinal tract, compromising its ability to maintain mucosal integrity. This ischemic condition increases the risk of stress ulcer formation.

10. The patient is being admitted to the hospital. At home, the patient takes an over-the-counter supplement of vitamin D and is concerned because the doctor did not order that vitamin D to be given in the hospital. The nurse explains that a. the body does not store vitamins so the doctor will have to be called. b. the kidneys will produce enough vitamin D and that supplements are not needed. c. over-the-counter supplements are never given in the hospital. d. vitamin D is stored in the liver with a 10-month supply to prevent deficiency.

ANS: d.) vitamin D is stored in the liver with a 10-month supply to prevent deficiency. a. the body does not store vitamins so the doctor will have to be called:This is incorrect. While some vitamins are water-soluble and not stored in the body (like vitamin C), fat-soluble vitamins (like vitamin D) can be stored. b. the kidneys will produce enough vitamin D and that supplements are not needed:This is misleading. The kidneys do play a role in converting vitamin D to its active form, but they do not produce vitamin D; it is synthesized in the skin through sunlight exposure or obtained from diet. c. over-the-counter supplements are never given in the hospital:This is incorrect. While hospitals may have protocols about supplements, it is not true that they are never given. It depends on the patient's needs and medical orders. d. vitamin D is stored in the liver with a 10-month supply to prevent deficiency:This is correct. The liver stores vitamin D, allowing the body to draw on these stores when needed, which can help prevent deficiency for an extended period.

3. When caring for the patient with upper GI bleeding, the nurse assesses for which of the following? (Select all that apply.) a. Severity of blood loss b. Hemodynamic stability c. Vital signs every 30 minutes d. Signs of hypervolemic shock e. Necessity for fluid resuscitation

a. Severity of blood loss b. Hemodynamic stability e. Necessity for fluid resuscitation ANS: A, B, E Initial evaluation of the patient with upper GI bleeding involves a rapid assessment of the severity of blood loss, hemodynamic stability and the necessity for fluid resuscitation, and frequent monitoring of vital signs and assessments of body systems for signs of hypovolemic shock. Vital signs should be monitored at least every 15 minutes.

43. The nurse is caring for a critically ill patient with end-stage liver disease. The nurse knows that the patient is at risk for hyperdynamic circulation and varices. Which of the following assessments would indicate a hyperdynamic status? a. Jugular venous distension b. Normal sinus rhythm on the cardiac monitor c. Blood pressure of 180/90 mm Hg d. Stools

a. Jugular venous distension ANS: A Portal hypertension causes two main clinical problems for the patient: hyperdynamic circulation and development of esophageal or gastric varices. Liver cell destruction causes shunting of blood and increased cardiac output. Vasodilation is also present (so vasodilators are not needed), which causes decreased perfusion to all body organs, even though the cardiac output is very high. This phenomenon is known as high-output failure or hyperdynamic circulation. Clinical signs and symptoms are those of heart failure and include jugular vein distension, pulmonary crackles, and decreased perfusion to all organs. Blood pressure decreases, and dysrhythmias are common. Guaiac-positive stools may be an indication of gastrointestinal bleeding.

2. The nurse is caring for a critically ill patient with respiratory failure who is being treated with mechanical ventilation. As part of the patient's care to prevent stress ulcers, the nurse would provide: (Select all that apply.) a. vagal stimulation. b. proton pump inhibitors. c. anticholinergic drugs. d. antacids. e. cholinergic drugs.

b. proton pump inhibitors. c. anticholinergic drugs. d. antacids. ANS: B, C, D Administration of antacids and H2-receptor blockers, and the suppression of vagal stimulation with anticholinergic drugs and proton pump inhibitors (PPI) are effective forms of therapy.

30. The nurse is caring for a patient who has a Sengstaken-Blakemore tube in place. In caring for this patient, the nurse must a. maintain as little traction as possible. b. apply external traction using a side rail of the bed. c. deflate the gastric balloon before the esophageal balloon. d. deflate the esophageal balloon before the gastric balloon.

d. deflate the esophageal balloon before the gastric balloon. ANS: D It is crucial that the esophageal balloon be deflated before the gastric balloon is deflated, or else the entire tube will be displaced upward and occlude the airway. Correct positioning and traction are maintained by using an external traction source or a nasal cuff around the tube at the mouth or nose. External traction can be attached to a helmet or to the foot of the bed (not the side rail). Proper amounts of traction are essential because too little traction lets the balloon fall away from the gastric wall, resulting in insufficient pressure being placed on the bleeding vessels. Too much traction causes discomfort, gastric ulceration, or vomiting.

3. The nurse is caring for a patient who has a peptic ulcer. To treat the ulcer and prevent more ulcers from forming, the nurse should be prepared to administer a. H2-histamine receptor blockers. b. gastrin. c. vagal stimulation. d. vitamin B12.

ANS: a.) H2-histamine receptor blockers. a. H2-histamine receptor blockers: H2 blockers reduce the amount of acid produced by the stomach, helping to treat peptic ulcers and prevent new ones from forming. b. Gastrin:Gastrin is a hormone that stimulates the secretion of gastric acid. Administering gastrin would actually increase stomach acid production, which could worsen peptic ulcers rather than help treat them. c. Vagal stimulation:Vagal stimulation can increase gastric acid secretion. While it affects digestion, stimulating the vagus nerve is not a treatment for peptic ulcers and could exacerbate the condition. d. Vitamin B12:Vitamin B12 is important for overall health, particularly for nerve function and blood cell production. While some ulcer treatments can lead to B12 deficiency, administering B12 doesn't treat the ulcer itself or prevent future ulcers.

4. Nursing priorities for the management of acute pancreatitis include: (Select all that apply.) a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. c. withholding analgesics that could mask abdominal discomfort. d. stimulating gastric content motility into the duodenum. e. utilizing supportive therapies aimed at decreasing gastrin release.

a. managing respiratory dysfunction. b. assessing and maintaining electrolyte balance. e. utilizing supportive therapies aimed at decreasing gastrin release. ANS: A, B, E Nursing and medical priorities for the management of acute pancreatitis include several interventions. Managing respiratory dysfunction is a high priority. Fluids and electrolytes are replaced to maintain or replenish vascular volume and electrolyte balance. Analgesics are given for pain control, and supportive therapies are aimed at decreasing gastrin release from the stomach and preventing the gastric contents from entering the duodenum.